The death of a loved one, with the experience of mourning that follows, is an inevitable event for each of us. Mourning is a normal, physiological response to loss, which is characterised by a temporary disruption of the individual's psychophysical balance.
Deep sadness and loneliness, nostalgia, intrusive images of the departed person, insomnia, lack of appetite, and difficulty concentrating are some of the most typical manifestations of acute bereavement. But when does mourning become pathological?
complex bereavement: a definition
What is complicated or pathological bereavement? Usually the main manifestations of bereavement die out or subside over a period of 6 to 12 months. When the acute manifestations of grief extend beyond this time frame, we can speak of complicated persistent grief disorder.
Pathological bereavement and DSM-5
What is pathological bereavement? Not everyone who thinks 'I can't get over a bereavement' falls under psychopathological functioning. Let us look at the criteria for the diagnosis of persistent grief disorder in the DSM-5. The death of a loved one in unprocessed grief according to the DSM-5 is manifested by:
persistent nostalgia for the person who has died
intense sadness, excessive anger or emotional anaesthesia
preoccupation with the deceased and the circumstances of the death
excessive avoidance of memories of the deceased
self-evaluation or guilt
disbelief about the loss
difficulty indulging in positive memories about the deceased.
These symptoms should occur at least 12 months after the bereavement in adults and at least 6 months in children.
Pathological bereavement and adjustment disorder
A differential diagnosis must also be made between pathological bereavement and adjustment disorder, defined by the DSM-IV as 'a psychological response to one or more identifiable stressors leading to the development of clinically significant emotional or behavioural symptoms'. While the symptoms of adjustment disorder must appear within three months of the stressful event, for complicated bereavement at least six months must have elapsed since the loss.
Unprocessed grief: the symptoms
We have seen how physiological grief and pathological grief are distinguished by a persistence of acute grief symptoms beyond 12 months. What consequences can an unprocessed bereavement cause? Symptoms for the individual who does not grieve can be
somatic, e.g. shortness of breath and loss of energy
intrapsychic, i.e. feelings such as sadness and anger
behavioural, with sudden crying and loss of interest.
The consequences of unprocessed grief can also manifest themselves in different family areas:
communication: for example, there may be a major increase or decrease in communication
the structure of the family: confusion in family roles, changes in the number of family dyads or triads, i.e. in the relationships between individuals
relationships within individual subsystems: for example, in couples, there may be emotional estrangement between spouses
extra-familial relationships, characterised by isolation and estrangement from friends.
Complicated grief: risk factors
Studies on complicated bereavement have also focused on prevention, so as to identify those most likely to suffer pathological bereavement before it occurs. In a preventive perspective, death education interventions are also very important. But what are the characteristics of the people most susceptible to persistent grief disorder? One discriminant seems to be attachment style. Research by Bonanno and Fraley (2004) showed that insecure attachment style is linked to complications in the bereavement process. Other potential risk factors for persistent grief disorder are:
lack of social support
alexithymia
low self-esteem
external locus of control
poor quality of the relationship with the deceased.
In the latter case, think for instance of a conflictual relationship suddenly interrupted by bereavement. The loss thus takes on the appearance of an unfinished gestalt, a circle that can be difficult to close. In these cases, in order to grieve it is useful to re-establish dialogue with the deceased, so as to express unspoken emotions and finally make peace with the past .
When mourning does not want to end
What happens when one fails to grieve? Unprocessed bereavement among its consequences can initiate psychopathological functioning such as:
post-traumatic stress disorder
traumatic drug addiction
major depression or dysthymia.
Let us look at them in detail.
Post-traumatic stress disorder and bereavement
Sometimes grieving over a loss can be equivalent to experiencing trauma. Failure to cope with a particularly traumatic bereavement can in fact contribute to the onset of post-traumatic stress disorder (PTSD), a syndrome that can lead to the development of a symptomatic condition that causes considerable suffering.
A bereavement is traumatic when the loss of a loved one occurs under special circumstances (e.g. homocide or suicide). This event is the equivalent of a narcissistic wound that provokes anger and a desire for vindication for the loss suffered, intrusive thoughts related to the deceased (his or her last moments, the degree of suffering experienced or the nature of the death), avoidance behaviour, sleep disturbances, concentration difficulties and, in children, repetitive play.
The most appropriate psychotherapy work with people who have developed sudden bereavement trauma is bereavement and trauma processing.